a client who had an elective below the knee amputation reports pain in the foot that was amputated what is the best response by the nurse
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Nursing Elites

ATI RN

Multi Dimensional Care | Final Exam

1. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?

Correct answer: D

Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.

2. When providing a routine bed bath, what action does the nurse complete first?

Correct answer: D

Rationale:

3. The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?

Correct answer: C

Rationale:

4. A nurse is teaching a newly hired group of unlicensed assistive personnel about infection-control measures on the unit. What is the most effective way to prevent the spread of pathogens during client care?

Correct answer: B

Rationale:

5. Which finding is not typically associated with inflammation in a client?

Correct answer: C

Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.

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